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Personal Representative Request Form

 Personal Representative Request Form
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Category: Confidentiality and Nondisclosure - Contracts - Protected Health Information - HIPAA
State:Multi-State
Control #:  US-3578
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Available formats: Adobe PDF
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Description

This form is used by a health plan to identify a representative of a subscriber who has legal authority to make health care decisions for the subscriber, such as a guardian, person appointed in a power of attorney, or other documented authority.


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